Diagnosis, management, and long-term outcomes of rectovaginal endometriosis

Abstract

Rectovaginal endometriosis is the most severe form of endometriosis. Clinically, it presents with a number of symptoms including chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia, and rectal bleeding. The gold standard for diagnosis is laparoscopy with histological confirmation; however, there are a number of options for presurgical diagnosis, including clinical examination, transvaginal/transrectal ultrasound, magnetic resonance imagining, colonoscopy, and computed tomography colonography. Treatment can be medical or surgical. Medical therapies include birth control pills, oral progestins, gonadotropin-releasing hormone agonists, danazol, and injectable progestins. Analgesics are often used as well. Surgery improves up to 70% of symptoms. Surgery is either ablative or excisional, and is conducted via transvaginal, laparoscopic, laparotomy, or combined approaches. Common surgical techniques involve shaving of the superficial rectal lesion, laparoscopic anterior discoid resection, and low anterior bowel resection and reanastomosis. Outcomes are generally favorable, but postoperative complications may include intra-abdominal bleeding, anastomotic leaks, rectovaginal fistulas, strictures, chronic constipation, and the need for reoperation. Recurrence of rectal endometriosis is a possibility as well. Other outcomes are improved pain-related symptoms and fertility. Long-term outcomes vary according to the management strategy used. This review will provide the most recent approaches and techniques for the diagnosis and treatment of rectovaginal endometriosis.

Keywords: bowel resection; dyspareunia; endometriosis; pelvic pain; rectovaginal.

Figure 1

This is an endorectal ultrasound revealing a deep endometriosis nodule involving the muscular layer of the rectum. Note: Copyright © 2013. Reproduced with permission of Elsevier. Roman H, Vassilieff M, Tuech JJ, et al. Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum. Fertil Steril. 2013;99(6):1695–1704.

Figure 2

This is a modified virtual colonography with transparent views of the rectum and lower sigmoid. Notes: The strictured area in the rectogenital area is indicated by arrows. The L, S, and D in the figure are from the LSD/MURO classification system. Copyright © 2013. Reproduced with permission of Elsevier. van der Wat J, Kaplan MD, Roman H, Da Costa C. The use of modified virtual colonoscopy to structure a descriptive imaging classification with implied severity for rectogenital and disseminated endometriosis. J Minim Invasive Gynecol. Epub June 5, 2013. Abbreviations: L, length; S, stricture; D, distance to the anal verge; MURO, describes disseminated endometriosis beyond the rectogenital organs.

Figure 3

This is a preoperative assessment using magnetic resonance imaging, revealing a deep infiltrating endometriosis nodule with an obvious increase in rectal wall thickness. Notes: The increase in rectal wall thickness is indicated by the arrow. Copyright © 2013. Reproduced with permission of Elsevier. Roman H, Vassilieff M, Tuech JJ, et al. Postoperative digestive function after radical versus conservative surgical philosophy for deep endometriosis infiltrating the rectum. Fertil Steril. 2013;99(6):1695–1704.

Figure 4

This is an endometriotic stricture >30% managed by segmental resection. Note: Copyright © 2013. Reproduced with permission of Elsevier. van der Wat J, Kaplan MD, Roman H, Da Costa C. The use of modified virtual colonoscopy to structure a descriptive imaging classification with implied severity for rectogenital and disseminated endometriosis. J Minim Invasive Gynecol. Epub June 5, 2013.